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THE UNITED STATES is facing a nursing shortage, but 30% to 50% of all new nurses will leave their profession sometime during their first 3 years of practice.1 Much of this can be attributed to workplace incivility, at a cost of $24 billion annually.2

Incivility is a low-intensity behavior, or a milder form of uncivil behavior, with the intent to harm the target.3

Bullying is intentional and repeated aggression toward another person with intent to harm the target.4

Lateral violence is nurses aiming their dissatisfaction with work in a negative manner toward others in an equal or lesser position using uncivil behavior.5

All forms of uncivil behavior involve toxic or dysfunctional interpersonal relationships that are linked to high employee turnover and lower quality of care.1 This article explores the many levels of workplace incivility and effective methods for addressing them.

Nursing responsibility

The American Nurses Association Position Statement on incivility, bullying, and workplace violence states that RNs must make “a commitment to—and accept responsibility for—establishing and promoting healthy interpersonal relationships with one another.”6 Nurses must also be aware of how their own communications and behavior or lack of action may contribute to incivility.

Nearly 60% of nurses have reported witnessing others being bullied, but most either don't recognize it or they ignore it; either way, it goes unreported and unaddressed.7 When senior nurses role-model workplace incivility to novice nurses in the workplace, those behaviors are perpetuated and become the social norm.8 This is particularly alarming because a culture of incivility undermines patient safety as well as professional teamwork. Compromises in patient safety have been linked to medical and medication errors, increases in sentinel events and patient mortality, and decreased quality of care overall.2

To maintain patient safety, The Joint Commission has mandated that all hospitals receiving federal funds resolve workplace incivility. Policies and procedures should include “a code of conduct, accountability for behaviors, zero tolerance for intimidating behaviors, and a nonretaliation clause for reporting lateral violence in the workplace.”9 Education must also be provided for collaboration and relationship building.

New nurses report severe depression as a direct result of incivility affecting their ability to concentrate and perform their nursing duties.2 Consider, for example, the case of a new RN in the ICU who isn't sure how to calculate a dobutamine dose prescribed for her patient. When she asks a seasoned RN for assistance, she's told, “I don't have time right now.” As a result, the new nurse miscalculates the dose. The seasoned RN's dismissive response to a request for help paved the way for a serious medication error. The new RN could have called the pharmacist, but in the face of uncivil behavior directed toward her, she might not be thinking clearly enough to recognize this other resource.

Many forms of workplace incivility

Verbal abuse includes publicly criticizing a coworker; gossiping or backstabbing; and yelling, shouting, or swearing.10

Nonverbal abuse includes eye rolling, staring or glaring, making faces, or excluding someone from a conversation or work activities.10

Passive-aggressive behavior is refusing to communicate, failure to support a coworker, or sabotaging or setting up a coworker to fail. This behavior can be subtle and may be difficult for outsiders to identify as workplace incivility.10

Bullying is defined by Sanders and Phye as occurring when a person is exposed repeatedly to negative actions by another person, so bullying encompasses all of the above behaviors.11 This would include accusing a nurse of errors made by someone else, assigning undesirable work, and giving invalid criticism.2 The two most common bullying behaviors are expecting someone to do others' work and reprimanding someone in front of others.7

Taking steps to address incivility

All facilities need to develop and enforce a zero-tolerance policy for incivility. Uncivil behaviors should be clearly outlined and defined. All staff should understand that incivility won't be tolerated, and if it occurs, consequences will result. For example, a nurse who exhibits uncivil behavior would be given a verbal and written warning for each infraction, and after three infractions, the nurse would be terminated. This is very effective as it places those practicing incivility “on notice.”

Once a policy is in place, staff-development programs need to be held for staff and managers about the zero-tolerance policy for bullying and incivility. These programs can include education about improving communication skills, challenging perpetrators, and using silence to promote thinking.12 Using silence is an effective method of encouraging staff members to talk to their director. If the director speaking to a staff member keeps fairly quiet, this will encourage the staff member to answer because most people find it difficult to refrain from speaking when everyone else is silent. All nurses need to be confident enough to confront incivility.

Team-building sessions should be held in all facilities. These should focus on building trust, clarifying roles, engaging staff in decision making, and role-modeling positive interactions.9 Simulation can be used for these sessions, leading to better teamwork and collaboration. For example, the simulation could involve a staff member role-modeling positive interactions with other nurses to demonstrate the power of positivity in staff communications.

Dealing with incidents

Incivility isn't always obvious. It can simply be eye rolling or making derisive sounds. Reports of incivility in the workplace should always be taken seriously, even if the behavior isn't easily spotted. All incivility incidents should be documented by the target and kept in a safe place, as they're part of the record of the incidents.

When reporting incidents or confronting the perpetrator, use “I” statements instead of “you” statements to verbalize your position. No one can argue with how something made you feel.13 This also helps to prevent defensive behavior, which can escalate a confrontation. An example of an “I” statement is, “I feel frustrated and demeaned when I'm not given help when I ask for it.” This keeps the focus on the behavior and not the person.

Nurses who've been bullied need to confront the aggressor in private when they're calm. The confrontation may need to be arranged with the nurse manager. The target should clearly state that the behavior isn't acceptable.13 If the nurse manager is the bully, the next higher person in command can be notified and can arrange a conversation with all parties involved. This is a particularly difficult situation, but to address the problem, the confrontation must occur.13

This might necessitate a mediated conversation (crucial conversation), where the stakes are high for all members and opinions vary.14 In a crucial conversation, all sides of an issue are presented, by one person at a time, and then a compromise or solution is reached. Using this approach, all sides feel they've been heard and their needs have been met. As a result, these mediated conversations generally end with an issue being resolved.14 Follow-up meetings should be scheduled to assess resolution of the situation.

Using cognitive rehearsal

Griffin developed cognitive rehearsal as a response to workplace incivility. Using this method, new nurses or any nurses having problems with incivility are given cue cards with the 10 most common forms of incivility in the workplace and the appropriate responses for confronting them.15 They then receive 2 hours of education about workplace incivility and how to manage it. New nurses report that confronting lateral violence is difficult but does tend to stop the bullying behaviors.16

Griffin and Clark revisited the use of cognitive rehearsal and found that several studies had used it as an evidence-based strategy to address uncivil and bullying behaviors in nursing and found it to be effective.15 The American Nurses Association's position statement on workplace incivility or bullying includes Bullying Tip Cards, which nurses can use to confront incivility.6

Role of simulation

When using simulation within the hospital to teach nurses skills for resolving nursing problems in patient care, educators can include scenarios that also teach them how to deal with incivility. For example, a simulation might be about a patient with heart failure whose cardiac output has been declining for two shifts. To resolve the issue, the oncoming nurse needs to speak to the charge nurse about whether to call the healthcare provider, but the charge nurse is uncivil and refuses to help.

The simulation would use appropriate techniques to resolve both the clinical issue and the incivility issue using appropriate communication techniques. If communication with the charge nurse wasn't enough to change the uncivil behavior, then the next step would be to report it to the manager.

Nurse-to-nurse incivility

By far the most common type of incivility is nurse-to-nurse incivility. It's associated with high rates of employee turnover and decreased quality of care. Many nurses, and especially new graduates, have experienced this type of incivility.1 One example would be the new nurse who asks for assistance to program an infusion pump. Instead of assisting him or her, the seasoned nurse belittles the new nurse in front of other staff for needing any assistance at all. Self-blame and failure to report the bullying is common because one pattern of response to bullying is to remain silent, which allows for escalation of the bullying.9

Remember that the focus of discipline should be on the behavior and not on the person. Focusing on the person demeans him or her and decreases morale. It can also trigger a backlash of incivility and negative feelings toward the victim who reported the behavior. The goal is to stop the uncivil behavior and maintain the confidence of the person or persons involved and to improve interpersonal relationships.13

Manager-to-nurse incivility

Those in supervisory positions should be held accountable for unprofessional behavior. These behaviors might include favoritism for certain nurses, exclusion of nurses from committee work or meetings that might be more beneficial and productive with the input of those nurses, or setting up barriers for nurses pursuing advanced degrees, such as scheduling conflicts or lack of support. They may be selective with staff about requests to attend nursing conferences, or they may be inconsistent with disciplinary actions.12 Nearly half of nurses bullied by supervisors feared retaliation if they reported the bullying. Others simply left their nursing position to end the bullying.18

Tolerating uncivil behavior continues the cycle of incivility. Managers who are uncivil themselves or who refuse to address an incivility issue should be reported up the chain of command. Human Resources needs to get involved to help solve the issue.

Physician-to-nurse incivility

Incivility from physicians and other healthcare providers also occurs, especially with new nurses. This should always be reported to the nurse manager or the next nurse in the chain of command. An example would be the new ICU nurse with a critically ill patient who needs hourly blood glucose level monitoring and assessments. Every hour for 4 hours these levels have to be reported to the physician on call because they're outside the guidelines left by the primary physician. After the fifth call, the physician on call refuses to hear the nurse's report, and yells, “Don't call me again tonight,” and hangs up.

This happened to me, and though very difficult, it had to be reported to the charge nurse, documented, and sent on to that physician's supervisor. It wasn't easy coming face to face with that physician the following week, but the physician apologized and was never uncivil with me again.

Simulation would be an excellent way to address this form of incivility. Interprofessional collaboration, using nurses and medical residents in the simulation, can be used to demonstrate the occurrence and resolution of physician-to-nurse incivility.

Patient-to-nurse incivility

My most memorable experience with patient incivility was the patient who threw his breakfast tray across the room at me after I asked him, “How are you feeling today?” I calmly picked up the tray and told him that if he had a concern, I'd be glad to notify my supervisor. He didn't respond. I left the room and quickly reported the incident to my nursing supervisor, who contacted the patient liaison. They worked with the patient to resolve his concerns of having very little physical activity while in the hospital and his dislike of his physician.

This type of incivility can be very unsettling. Simulation can also be used to teach nurses how to deal with patient incivility. Always document the incident in a professional manner, using only the facts rather than emotions. Documentation can take place in a private area while on a break, or in the privacy of one's home. A patient liaison can also be used.

Promoting a more civil workplace culture

Workplace incivility makes for a negative work environment and low morale. The workplace culture can be enhanced if nurses are encouraged to communicate effectively and resolve issues. This in turn promotes patient safety and excellent nursing care, and promotes nurse retention. Nurses who work well with their colleagues can achieve improved patient outcomes.

6.
American Nurses Association. Professional issues panel on incivility, bullying, and workplace violence. 2015. New position statement. http://www.nursingworld.org/DocumentVault/Position-Statements/Practice/Position-Statement-on-Incivility-Bullying-and-Workplace-Violence.pdf.